Surgery in ulcerative colitis: sooner or later?

Whether or not surgery for ulcerative colitis should occur sooner or later has been the source of debate between surgeons and physicians for some time. The issue was the source of lively discussion, at the British Society of Gastroenterology’s recent conference, and was debated by Professor Chris Hawkey, the new BSG president and professor of gastroenterology at Queen’s Medical Centre, Nottingham, and Bruce George, consultant general and colorectal surgeon at the John Radcliffe Hospital in Oxford and honorary senior clinical lecturer at the University of Oxford. “The obvious answer is that surgery should be performed sooner when necessary,” said Bruce George. “Recent developments which inform this debate include the publication of a paper in the BMJ. This was an epidemiological study with a cohort of around 3,000 patients in hospital with IBD. Patients who had elective colectomy had a relatively good survival rate of up to two years, while those who were admitted as emergency admissions for ulcerative colitis had a poorer mortality rate – whether or not they received an immediate colectomy.” The tried and “trusted” therapy for acute, severe colitis, he pointed out, included: the use of steroids, correction of electrolyte balance, heparin prophylaxis, abdominal X-ray, stool culture for Clostridium difficile, joint medical and surgical review with close monitoring of the patient. The traditional view is that, if the patient has not responded after five days, to intensive therapy, colectomy should be considered. “The crux of the debate is whether we should opt for relatively early surgery in this group of patients, or delay surgery. Early surgery runs the risk of not giving drugs a decent chance to work, which could lead to unnecessary surgery. This needs to be avoided where appropriate. Dangers arising from delaying surgery, on the other hand, include risks associated with protracted length of therapy and result from the fact that a much sicker patient presents for colectomy. This carries increased risks of morbidity and mortality.” He pointed out that in the 1930s, 75% of people with acute, severe colitis died within one year of presentation. Steroids have improved this outlook dramatically and a landmark trial suggested that their use reduced mortality to around 7%. The latest IBD audit results showed that, out of 205 patients identified with acute, severe colitis, six patients died. Acute, severe colitis remains a dangerous condition with a significant mortality, therefore. “There is no doubt that new drugs introduced after 3-4 days of intensive medical therapy do work. Most studies examining cyclosporin report a good response rate of 60-80%, with some risks of toxicity,” Bruce George continued. “Similarly, infliximab has shown efficacy – perhaps better in slightly milder disease – but, again, there are some risks in the long term. “I think it is fair to say that surgery, when required, has slightly better results. The correct operation in the acute phase – in patients on corticosteroids and other medication – is a total colectomy, formation of end ileostomy with preservation of the rectum. There is no place for proctocolectomy with a restorative pouch in the acute context – the results are unacceptably poor in this situation.” He added that an improvement in recent years has been the introduction of laparoscopic colectomy. Trials have shown that there is shorter length of hospital stay, patients recover more rapidly and there is an earlier return to diet and bowel function compared to open surgery, but no overall difference has been found in short-term complication rates. “Whether performed laparoscopically or through open surgery, emergency colectomy does result in some morbidity. An important point to make is that surgery at the acute phase appears to be more hazardous,” he continued. He highlighted a study that showed that the only risk factor found to be a predictor for major complications was the duration of medical therapy preoperatively. “Patients who had surgery later on, with a protracted period of medical therapy, were more likely to experience major complications,” he explained. Further research also showed that mortality for colectomy, when undertaken more than six days after admission, was twice as high compared to earlier surgery. “There is a huge difference between someone who is admitted with their first attack of colitis compared to someone who has an acute, severe attack and is already on optimum medical therapy,” he acknowledged. “The more severe the disease, the more likely the patient will need a prompt colectomy.” He concluded: “Delayed surgery is associated with a higher risk of both morbidity and mortality; while surgical techniques have improved in recent years. However, the importance of joint medical and surgical management cannot be over emphasised. They key factor is predicting those patients who have severe disease and need a colectomy sooner.” Chris Hawkey argued against a policy of earlier surgery, commenting: “IBD care could be significantly improved by managing patients better so that they do not need surgery. If we make the wrong decision with regards to surgery, whether it is too early or too late, it is a bad result. Our assumptions about when to operate are also probably wrong.” He added that he did not think surgery should be performed earlier than five days after treatment on admission, as this would be “reckless management”, and raised the question: “Are steroids necessarily the best approach?” “These agents are associated with infectious and total postoperative complications,” he commented and asked: “Should we revisit the notion, which emerged from Belgium a few years ago, that steroids should be replaced with cyclosporin?” “It is time to rethink what we do,” he exclaimed. “The Oxford ‘five-day’ regime was based on a number ‘plucked out of the air’ in the 1970s. This may, or may not, have been the right approach then, but we should ask ourselves: is it is right now?” There is no evidence to support this regime, in his opinion. He critiqued a paper by Kaplan which claimed that mortality increases the longer surgery is delayed: “What this tells us is that people who have late surgery do less well – not that late surgery makes them unwell. When a patient has late surgery, it may be because they have not been properly managed, intensively, but there is an alternative view. These may be patients who, on day three, were too sick to undergo surgery. “The procedure may have been delayed, not because they were too sick from colitis, but because of co-morbid medical conditions. Therefore, the general policy of early surgery is not the same as better management.” He commented that effective, focused, multi-disciplinary management is crucial – whether this means a decision is made sooner or later to perform surgery – and pointed out that patients are not as “actively monitored as they should be”. “Deaths occur in patients with comobidity – regardless of whether they have surgery and this is exactly what the BSG IBD audit has shown,” Prof. Hawkey commented. A third of patient deaths were due to ulcerative colitis – others died because of heart attacks, respiratory disease and renal failure, i.e. they were patients with advanced cardiovascular disease. He asked: “Do we want to pursue a policy of ‘rushing in’ with these patients?” adding: “We may end up killing more of them, if we do. Quite defensibly, these are the patients that are having late surgery.” He pointed out that the severity of colitis is less than it used to be and comorbidities greater, prompting a need to rethink current strategy. “In the past, when dealing with peptic ulcers, we came to a realisation that there were alternatives to ‘rushing’ into surgery. We need to stand back and ask ourselves: is this where we are with colitis, in 2009? Pouch surgery is often described as ‘producing excellent results’ but the problem is that ‘good results’ are rarely defined,” he commented, adding: “A 50% incidence of incontinence and nocturnal seepage; 40% pouchitis; 23% small bowel obstruction; problems with conception and a lot of pelvic sepsis are not ‘a good result’.” “This treatment is ‘second best’ – we do not have a ‘first best’, so it is reasonable to adopt a policy of conservative management,” he continued. Prof. Hawkey highlighted evidence from studies where this conservative approach was pursued and pointed out that colectomy was avoided for many patients, with no increase in mortality. In one centre, 18% of patients retained their colon and were in good health in the long term. He also cited a paper that concluded that cyclosporin was not associated with a significant increase in postoperative complications. By contrast, infliximab was associated with a higher rate of post-operative complications. “This is something which we need to think about when we compare infliximab and cyclosporin,” he commented. “Quite possibly, early surgery may be appropriate for some, but, in general, I would like to see surgery considered later than five days. The statement that a policy of early surgery should be followed suggests a greater willingness to operate on patients with co-morbidities who are at higher risk from surgery. “Furthermore, if we operated on more patients, we would see more nonspecialist surgeons performing colectomy procedures which we know would result in a poorer outcome,” he added. He concluded that better management of IBD is required to avoid surgery and highlighted some of the predictors of relapse, commenting: “Patients with inadequately treated disease, who remain sub-clinically inflamed, go on to present at hospital with acute, severe colitis. Those who receive incomplete treatment for a recent attack of colitis are most at risk. Therefore, when we find inflammation, we should have a policy of suppressing it – even in the absence of mild symptoms. “We now have methods of detection which are much more sensitive. Yet when inflammation is detected in patients undergoing routine colonoscopies, there is often no intensification of treatment. We need to ensure surgery is performed later and less frequent through better medical management.” Prof. Hawkey called for more trials to support this approach, including studies to examine the treatment of inflammation in the absence of symptoms. Delegates were asked to vote “for” and “against” the motion for earlier surgery, prior to the debate, and the initial response was 50/50. Following the speakers’ presentations, a second vote took place and a majority vote was swayed in favour of Prof. Hawkey’s argument against early surgery. After the debate, Prof. Hawkey said that he and his opponent agreed that patients should be cared for actively and decisions on management – both medical and surgical – should be taken and implemented promptly and decisively.